Local control of locally advanced (N2) non-small cell lung cancer: when and how?

In patients with locally advanced (N2) non-small cell lung cancer (NSCLC), surgery alone results in dismal prognosis despite of its localized presentation by definition (1). As most locally advanced lung cancers are large and centrally located, extensive resection is expected for complete tumor removal. The incidence of postoperative complications is generally high, and functional impairments are often encountered after extensive surgery. Even if patients recover well following complicated surgery, oncologic outcomes are poor because of the high rate of distant failures (2). Therefore, invasive mediastinal staging is widely adopted in many centers for all potentially operable NSCLC patients to identify N2 NSCLC patients and to avoid risky and ineffective surgery (1). The European Society of Thoracic Surgeons guidelines strongly recommend invasive mediastinal staging in the presence of 1 or more of the following criteria: central location of lesion, tumor size >3 cm, or suspicion of N1 nodes (3)